Wednesday, 2 January 2013

Liverpool Care Pathway – A Certain Uncertainty

This comment left on the LCP Facebook pages:

"The CMF stance on the LCP has never satisfied me. They are in favour of the LCP if "used properly" and when death is "imminent" - I still ask if anyone can ever be 100% sure that a person is going to die within ? hours/days ... and what right anyone has to make this assertion in the first place!"

Liverpool Care Pathway – nine points for the government to consider in its reviewTo iron out the abuses that have been reported, several key measures need to be implemented:

1.It should be made absolutely clear that no one who is not imminently dying within hours, or at most two or three days, should be placed on the LCP and anyone placed on it who shows improvement should be taken off it. These assessments should be made by senior clinicians.

2.No one should be placed on the LCP without it being discussed with the relative or carer (although the latter do not need to give consent).

3.Every patient placed on the LCP must be regularly monitored and reassessed by a multidisciplinary team.

4.The present documentation is far too complex and needs to be simplified and standardised so that those implementing it can easily follow the guidelines and supervisors can easily tell what is going on with each patient.

5.Training and supervision of those using the pathway needs to be standardised and improved and formal training should be required before any healthcare professional is able to use it.

6.An annual audit needs to be carried out and all suboptimal use identified promptly acted upon.

7.Non-clinical priorities in the use of the pathway, especially financial priorities, must be eradicated and every patient treated solely according to their need. In this connection it would be far better to link CQUIN payments to staff training in the use of the pathway rather than numbers of patients placed on the pathway.

8.Communication to relatives both by health professionals and organisations involved in LCP implementation needs to be substantially improved.

9.Those misusing the LCP should be quickly identified and in the case of abuse reported to the appropriate authorities (General Medical Council, Nurses and Midwifery Council or Health and Care Professions Council).

‘The LCP represents a pragmatic and effective response to some of the suffering experienced by many in the last days of life. It remains, however, a tool and it is only as good as those who use it. There is always potential for misuse and abuse and there are undoubtedly instances where this occurs. Where these arise by intention then those involved should be held to account, but more often they occur through poor understanding and inadequate training. We owe it to patients to not only furnish the means to better care, but also to equip adequately those who provide it.’

An influential group of Christian doctors yesterday called for an end to financial ‘bribes’ that encourage hospitals to place dying patients on the controversial Liverpool Care Pathway.

The Christian Medical Fellowship said judgments about whether to withdraw treatment from terminally-ill patients should be made solely on clinical grounds.

The CMF, which represents more than 4,000 doctors, said financial incentives for hospitals to use the system – thought to run at more than £10million a year in total – should be ‘eradicated’ immediately.

It also urged ministers to tighten controls to end the ‘undoubted abuses’ of a system designed to ensure patients die with dignity.

Dr Jeff Stephenson, a Devon-based consultant in palliative care, said the care pathway could help ease suffering if used properly.

But he added: ‘It remains a tool, and it is only as good as those who use it. There is always potential for misuse and abuse and there are undoubtedly instances where this occurs.

‘Where these arise by intention then those involved should be held to account, but more often they occur through poor understanding and inadequate training.

‘We owe it to patients to not only furnish the means to better care, but also to equip adequately those who provide it.’

A dangerous vehicle is still as dangerous in the hands of a trained driver.The determination that someone is going to die is a diagnosis of the futility of their condition and that it will result in death.If that person is already weak and frail, the rigours of the LCP protocols are going to make that outcome more likely.The advocates of the LCP make assurances that should the person improve they may be removed from the protocol. To make such assurances is to admit that wrong diagnoses do occur. It is not so certain, then, to determine with certainty that a person should be placed on the LCP...Footnotes:The report highlights a myriad of challenges of mainstreaming palliative care: the fact that most common chronic diseases (unlike cancer) have uncertain prognoses, which makes assessment of the need for palliative care difficult...

Placing a patient on the Pathway "is a decision with an end in view. The patient is dying. Why? Because we say they are dying. Why? Because we have decided.”

- Dr Philip Howard

Without a doubt, end-of-life care is fraught with complexity and controversy. For example, there is continuing debate whether it devalues life by abandoning curative efforts too early, or is more respectful of life as it seeks to give the dying greater dignity and quality of life. While most respect individual choice and one's right to die with dignity, interpretations—whether individual, societal, cultural, religious or clinical—of what constitutes "quality of life" in one's dying years vary greatly. There is also a lingering perception that palliative care can result in substandard medical treatment, or is a way to end the burden of caregivers.

‘The lack of evidence for initiating the Liverpool Care Pathway makes it an assisted death pathway rather than a care pathway.‘Very likely many elderly patients who could live substantially longer are being killed by the LCP.‘Patients are frequently put on the pathway without a proper analysis of their condition.‘Predicting death in a time frame of three to four days, or even at any other specific time, is not possible scientifically.This determination in the LCP leads to a self-fulfilling prophecy. The personal views of the physician or other medical team members of perceived quality of life or low likelihood of a good outcome are probably central in putting a patient on the LCP.’‘If we accept the Liverpool Care Pathway we accept that euthanasia is part of the standard way of dying as it is now associated with 29 per cent of NHS deaths.’- Professor Patrick Pullicino

1 comment:

Brilliant! Thank you so much for this. I've been working on a very complex letter regarding the LCP. The CMF's views - which I've not previously seen - reinforce a number of my points wonderfully. The fact that an organisation representing some 4,000 medical professionals expresses such views is a useful opposing view to the 1,000 odd signatures in favour of the LCP.

About Me

I am distraught and I despair that these events have befallen this family. The picture is of me and my lovely mum, murdered on the NHS (National-socialist Health Service). Murdered. Is that too strong a word? Her life was taken without her permission. By omission and by commission, actions taken and not taken conspired to end her life. She was kept in ignorance of what was proceeding before her very eyes, as were we. Was she, then, not murdered?